Does the presence of health insurance and health facilities improve access to healthcare for major morbidities among Indigenous communities and older widows in India? Evidence from India Human Development Surveys I and II

In this paper, we examine whether access to treatment for major morbidity conditions is determined by the social class of the person who needs treatment. Secondly, we assess whether health insurance coverage and the presence of a PHC have any significant impact on the utilisation of health services, either public or private, for treatment and, more importantly, whether the presence of health insurance and PHC modify the treatment use behaviour for the two excluded communities of interest namely Indigenous communities and older widows using data from two rounds (2005 and 2012) of the nationally representative India Human Development Survey (IHDS). We estimated a multilevel mixed effects model with treatment for major morbidity as the outcome variable and social groups, older widows, the presence of a PHC and the survey wave as the main explanatory variables. The results confirmed access to treatment for major morbidity was affected by social class with Indigenous communities and older widows less likely to access treatment. Health insurance coverage did not have an effect that was large enough to induce a positive change in the likelihood of accessing treatment. The presence of a functional PHC increased the likelihood of treatment for all social groups except Indigenous communities. This is not surprising as Indigenous communities generally live in locations where the terrain is more challenging and decentralised healthcare up to the PHC might not work as effectively as it does for others. The social class to which one belongs has a significant impact on the ability of a person to access healthcare. Efforts to address inequity needs to take this into account and design interventions that are decentralised and planned with the involvement of local communities to be effective. Merely addressing one or two barriers to access in an isolated fashion will not lead to equitable access.


Reviewer #1: Dear Editor
This is a good manuscript to publish in your valuable journal, but before making a decision, it needs a major revision, especially in the methods. 1-Analyzes do not include questionnaire questions for example: occurrence and duration of short-term and major morbidities, treatment received including hospitalization, costs incurred, … 2-Coverage ratios (CR) can be another option in presenting the results. 3-Major morbidities are unknown 4-The results are not well described and need to be rewritten. 5-In the dissection, of inequality and health coverage (UHC) and its relationship to outcomes be explained.

Response:
We thank the reviewer for the statement that this is a good manuscript to publish in the PLOS One valuable journals. This is indeed a very good manuscript and each point raised by the reviewer will be addressed below.
1. Analyzes do not include questionnaire questions for example: occurrence and duration of short-term and major morbidities, treatment received including hospitalization, costs incurred, …

Response:
We thank the reviewer for this comment, and all the questions mentioned above are great examples of potential research questions. Although the information on the type of treatment received, short-term and long-term morbidities and the costs, is available in the IHDS survey data, as reported in the manuscript, the main focus of the paper is on access to treatment. We are looking at the treatment seeking behaviour as the outcome variable; we are talking of people not able to reach to the hospital and that the social class factor is playing a significant part in this despite the presence of health insurance and health facilities. We clearly stated that in the manuscript the following (page 8, lines 225-229).
In this study, we look only at access to treatment for major morbidity, as the three conditions listed under short-term conditions are more likely to be treated using home remedies or non-prescription medication than in a formal healthcare setting. We define access to treatment as the ability of an individual who requires healthcare to obtain it irrespective of their social class.

Response:
We thank the reviewer for this comment, and it would be interesting to consider the insurance coverage ratios. However, we simply wanted to investigate the effect of the launched health insurance as a step towards the universal health coverage in India. The focus of our paper is on access to healthcare for the two socially excluded populations of interest and not primarily on the extent of health coverage of both populations with health insurance.
However, we admit that a term we have used in the title of the paper might be misleading and cause readers to miss the key focus of the paper. Hence, we are removing the world "utilisation" from the title and revising it as follows.
Does the presence of health insurance and health facilities improve access to healthcare for major morbidities among Indigenous communities and older widows in India?

Response:
We thank the reviewer for this comment but politely disagree with this comment as the details of the major morbidities are given in methods section where we describe our Data source and sample (page 6, lines 177-180; page 7, lines 181-183).

Response:
We thank the reviewer for this comment but politely disagree with this comment. As we described in the background section of our manuscript, the key focus of our paper is to understand whether the presence of health insurance and health facilities will have an impact on access to healthcare for socially excluded communities in India (Indigenous communities and Widows older than 60 years). We looked at these two measures as the main intervention to achieve Universal Health Coverage in India, that is, the Pradhan Mantri Jan Arogya Yojana (PMJAY) which seeks to improve access to healthcare through the provision of health insurance, and the health and wellness centres which are upgraded Primary Health Centres. Given this context, we would like to humbly state that the presentation of results is centred around the key variables that capture social exclusion, health insurance coverage and availability of a primary healthcare centre.
In the absence of any specific issues that the reviewer has raised with regard to the results section, we believe our current presentation should be adequate. However, we added the following in statistical analyses section to make clear what these results represent (page 12, lines 285-289).
In all model results, regression coefficients are presented in the log-odds scale. They represent differences in the log-odds scale; they have not been expressed in the odds ratio scale, as it is often the case for Binary outcome variable and logistic regression models. This presentation of results in the additive log-odds scale allows easy interpretation of the coefficients associated to the interaction terms which represent the moderation effects.

5.
In the discussion section, of inequality and health coverage (UHC) and its relationship to outcomes be explained.

Response:
We would like to thank the reviewer for this comment. In response, we have further added relevant details in the discussion section (page 22, lines 396-403) as follows.
A key means of operationalising inequality in India has been the caste system. It is well established that social exclusion practised through the caste system has a negative impact for individuals belonging to communities considered to be lower in the caste hierarchy. Widows across various castes are also considered to be lower in social status and therefore have a lesser claim on social resources. This means that such individuals despite having resources such as health insurance and the presence of health facilities are unable to access them unlike others who are considered to be higher in the caste hierarchy and do not suffer from social exclusion. We have also added the following sentences to explain the observed relationships (page 22, lines 405-408).
For both groups, the presence of health coverage and health facilities did not significantly modify this accessibility issue. The marginal improvement observed (moderation effect) was not large enough to soothe the inequal healthcare accessibility.
The discussion section made a link between quantitative results and earlier qualitative study findings (page 23 lines 414-421), showing that the observed relationships between access to treatment and the presence of both health coverage and health facilities were corroborated by the qualitative analysis. The qualitative piece of findings offered sound explanations of the negative relationships observed (see also page 23, lines 422-434).